Ovarian CancerOvarian Cancer
www.freelivedoctor.comwww.freelivedoctor.com
Differential Diagnosis of Adnexal MassDifferential Diagnosis of Adnexal Mass
Mature cystic teratoma
www.freelivedoctor.comwww.freelivedoctor.com
Differential DiagnosisDifferential Diagnosis
Young womenYoung women– Usually gynecologicUsually gynecologic– Often functional cystsOften functional cysts
PostmenopausalPostmenopausal– Benign neoplasmsBenign neoplasms
CystadenomasCystadenomas
– Higher risk of malignancy than premenopausalHigher risk of malignancy than premenopausal Metastatic cancers may first present as adnexal massesMetastatic cancers may first present as adnexal masses
www.freelivedoctor.comwww.freelivedoctor.com
Ovarian CancerOvarian Cancer
Incidence/Morbidity/MortalityIncidence/Morbidity/Mortality– Lifetime risk: approx 1/70Lifetime risk: approx 1/70
www.freelivedoctor.comwww.freelivedoctor.com
Types of Ovarian CancerTypes of Ovarian Cancer EpithelialEpithelial Germ CellGerm Cell
– DysgerminomaDysgerminoma– Immature teratomaImmature teratoma– Endodermal sinus tumorEndodermal sinus tumor– Embryonal carcinomaEmbryonal carcinoma– PolyembryonalPolyembryonal– ChoriocarcinomaChoriocarcinoma– MixedMixed
Sex Cord StromalSex Cord Stromal– Granulosa cellGranulosa cell– Sertoli-LeydigSertoli-Leydig– GynandroblastomaGynandroblastoma– UnclassifiedUnclassified
MetastaticMetastatic– BreastBreast– Kruckenberg- Primary usually stomach, signet ring cells on pathologyKruckenberg- Primary usually stomach, signet ring cells on pathology
www.freelivedoctor.comwww.freelivedoctor.com
Ovarian Cancer Staging
www.freelivedoctor.comwww.freelivedoctor.com
Ovarian Cancer Staging
www.freelivedoctor.comwww.freelivedoctor.com
Ovarian Cancer Staging
www.freelivedoctor.comwww.freelivedoctor.com
Ovarian Cancer Staging
www.freelivedoctor.comwww.freelivedoctor.com
Ovarian Cancer RisksOvarian Cancer Risks
Increase RiskIncrease Risk– Age most important independent risk factorAge most important independent risk factor– Family historyFamily history– BRCA1 (60x increased risk), BRCA2 (30x), BRCA1 (60x increased risk), BRCA2 (30x),
HNPCC (13x)HNPCC (13x)– Nulliparity, infertility, endometriosisNulliparity, infertility, endometriosis
Decrease RiskDecrease Risk– Prophylactic oophorectomyProphylactic oophorectomy– Oral contraceptive pillsOral contraceptive pills
www.freelivedoctor.comwww.freelivedoctor.com
ExamExam
PhysicalPhysical– Malignancy: irregular, Malignancy: irregular,
solid consistency, is solid consistency, is fixed, nodular, or fixed, nodular, or bilateral, is associated bilateral, is associated with ascites with ascites
www.freelivedoctor.comwww.freelivedoctor.com
ExamExam UltrasoundUltrasound
– Low positive predictive Low positive predictive value for cancervalue for cancer
– Cancer: excrescences, Cancer: excrescences, ascites, and mural ascites, and mural nodules nodules
– Benign: unilocular, thin-Benign: unilocular, thin-walled sonolucent cysts walled sonolucent cysts with smooth, regular with smooth, regular borders, regardless of borders, regardless of menopausal status or menopausal status or cyst size cyst size
Ovarian cancer
Benign cyst
www.freelivedoctor.comwww.freelivedoctor.com
LabsLabs
Tumor markersTumor markers– Epithelial: CA 125, elevated in 80% Epithelial: CA 125, elevated in 80%
35 U/mL is upper limit of normal35 U/mL is upper limit of normal Also elevated in many benign conditionsAlso elevated in many benign conditions
– Malignant germ cell tumors: b-hCG, LDH, AFP Malignant germ cell tumors: b-hCG, LDH, AFP – Embryonal carcinoma: AFP, BhCGEmbryonal carcinoma: AFP, BhCG– Endodermal Sinus tumor: AFPEndodermal Sinus tumor: AFP– Granulosa cell tumors: inhibinGranulosa cell tumors: inhibin
www.freelivedoctor.comwww.freelivedoctor.com
Work-upWork-up
PremenopausalPremenopausal– Symptomatic : evaluate as appropriate for Symptomatic : evaluate as appropriate for
tuboovarian abcess, ectopic, torsion, ruptured tuboovarian abcess, ectopic, torsion, ruptured ovarian cystovarian cyst
– B-HCG, CBC, transvaginal USN, cervical B-HCG, CBC, transvaginal USN, cervical culturesculturesTuboovarian abcess
Ectopic pregnancy
www.freelivedoctor.comwww.freelivedoctor.com
Work-upWork-up
PostmenopausalPostmenopausal– Exclude common diagnoses: endometriosis, cyst, Exclude common diagnoses: endometriosis, cyst,
abcessabcess– Higher index for suspicion: transvaginal USN, CA 125Higher index for suspicion: transvaginal USN, CA 125– Unless simple cysts, most likely will need surgeryUnless simple cysts, most likely will need surgery– Need breast exam, digital rectal, mammographyNeed breast exam, digital rectal, mammography
Ovarian Cancer
Ovarian Cancer
www.freelivedoctor.comwww.freelivedoctor.com
Treatment of Epithelial Ovarian Treatment of Epithelial Ovarian CancerCancer
ChemotherapyChemotherapy Cytoreductive surgery (debulking)Cytoreductive surgery (debulking)
CT of ovarian mass
www.freelivedoctor.comwww.freelivedoctor.com
Treatment of Epithelial Ovarian Treatment of Epithelial Ovarian CancerCancer
DebulkingDebulking
Removal of: uterus, tubes, ovaries, omentum, pelvic and paraaortic nodes, all visible tumor
Peritoneal washings
Diaphragm biopsieswww.freelivedoctor.comwww.freelivedoctor.com
Treatment of Epithelial Ovarian Treatment of Epithelial Ovarian CancerCancer
Carboplatin and PaclitaxelCarboplatin and Paclitaxel– First lineFirst line– Mechanism of actionMechanism of action
Carbo: binds and crosslinks DNACarbo: binds and crosslinks DNA Taxol: promotes formation and inhibits disassembly of stable Taxol: promotes formation and inhibits disassembly of stable
microtubules, inhibiting mitosismicrotubules, inhibiting mitosis
– Side effectsSide effects Carbo: thrombocytopenia, leukopenia, anemia, vomiting, hair Carbo: thrombocytopenia, leukopenia, anemia, vomiting, hair
lossloss Taxol: neutropenia, leukopenia, anemia, Taxol: neutropenia, leukopenia, anemia,
hair loss, muscle pain, vomiting, diarrheahair loss, muscle pain, vomiting, diarrhea
www.freelivedoctor.comwww.freelivedoctor.com